An Uncommon Cause of Elevated Liver Transaminases: Immune Reconstitution Inflammatory Syndrome from Unmasking of Occult Mycobacterium Avium Complex Infection in an HIV Infected Patient

Authors

  • John Ingram Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA Author
  • Abdallah Abdallah Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA Author
  • Zachary Field Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA Author
  • Tulip A Jhaveri Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, USA Author
  • Nathan Usry Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA Author
  • Neha Varshney Department of Pathology, University of Mississippi Medical Center, Jackson, USA Author
  • William Daley Department of Pathology, University of Mississippi Medical Center, Jackson, USA Author
  • Joydeep Chakraborty Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA Author

DOI:

https://doi.org/10.47363/JGHR/2024(5)164

Keywords:

Elevated Liver Enzymes, Elevated Transaminases, Immune Reconstitution Inflammatory Syndrome, Mycobacterium Avium Complex, Human Immunodeficiency Virus, Acid Fast Bacilli, Opportunistic Infection

Abstract

Abnormal liver chemistry from the development of immune reconstitution inflammatory syndrome (IRIS) may reflect an unmasking of subclinical disease. We present the case of a 37-year-old female with a mixed pattern of liver injury from disseminated mycobacterium avium complex infection after starting antiretroviral therapy (ART). Presenting symptoms were fever, confusion, dysphagia, and abdominal discomfort for one week. Exam revealed a fever of 103.2°F, hypotension, encephalopathy, and abdominal tenderness. Lab work was significant for acute normocytic anemia, leukopenia, absolute CD4 count 28 cells/cmm, HIV viral load 276 viral copies/ml (vc/ml), ALT 267 U/L, AST 484 U/L, alkaline phosphatase 342 U/L, and normal total bilirubin. Imaging revealed hepatomegaly with steatosis and mesenteric and retroperitoneal lymphadenopathy. Percutaneous liver biopsy demonstrated noncaseating granulomas with AFB-positive organisms, with AFB blood cultures growing Mycobacterium avium complex (MAC), consistent with disseminated MAC infection. Clinicians must have a high index of suspicion for IRIS when determining the etiology of elevated liver transaminases in patients with HIV. 

Author Biographies

  • John Ingram, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA

    Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA 

  • Abdallah Abdallah, Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA

    Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA

  • Zachary Field, Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA

    Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA 

  • Tulip A Jhaveri, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, USA

    Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, USA

  • Nathan Usry, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA

    Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA

  • Neha Varshney, Department of Pathology, University of Mississippi Medical Center, Jackson, USA

    Department of Pathology, University of Mississippi Medical Center, Jackson, USA

  • William Daley, Department of Pathology, University of Mississippi Medical Center, Jackson, USA

    Department of Pathology, University of Mississippi Medical Center, Jackson, USA

  • Joydeep Chakraborty, Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA

    Division of Gastroenterology and Hepatology, University of Mississippi Medical Center, Jackson, USA

Downloads

Published

2024-04-30

Issue

Vol. 5 No. 2 (2024): Volume 5 Issue 2

Section

Articles